Mr. Sridhar Venkapaturam
MSc Global Health and Social Justice Program, Department of Social Science, Health & Medicine, King's College London

Prof. Christian Lovis
Professor of Clinical Informatics and leading the Division of Medical Information Sciences, Geneva University Hospitals, Switzerland

Mr. Andrew Filev
Founder and CEO, Wrike, United States

AIM:

This session will gather a panel of people from various disciplines to debate the promises and challenges big data brings to global health.

OUTLINE:

As social systems move from the physical world to the virtual world, technology has served as an enabling factor that has made it possible for human capital to be developed, shared and applied in new ways and at an immense scale and pace. The potential for capturing natural data organically has accelerated profoundly as well as the potential to shed light on connections/linkages between sets of information that were until then not processed or just analyzed in silos. This increasing abundance of data, our ability to process it and use it meaningfully is causing what people have called a drift toward data-driven discovery and decision-making in various sectors including the health sector one. If data has become a core asset that provides a huge resource for new industries, processes, services and goods leading to significant competitive advantage, concerns for privacy and individual rights remain as well as how this new trend will benefit global health.

Prior to serve as Head of Strategy for Inartis Foundation, Dr. Bisognano founded and managed several companies such as Easymed Services Inc. (EZM:CN), a British Columbia, Canada, company. Dr. Bisognano had a post-doctoral position at the University Hospital of Geneva where he conducted research on molecular regulation of bacterial resistance. He is also the author of publications in international scientific journals and has obtained several awards for his research work (GSK and MSD Awards, Swiss Society for Infectious-Diseases). Dr. Bisognano was also a biotechnology consultant for Geneva’s government, research institutes and a Marketing Manager in a bioinformatics company. More recently, he co- directed a course on Biotech valuation for MoT MBA (federal polytechnic school) and collaborated with investment funds for their strategic portfolio allocation.

Angela Brand is Founding Director and Full Professor of the Institute for Public Health Genomics (IPHG) at the Faculty of Health, Medicine and Life Sciences at Maastricht University, the Netherlands, as well as Dr. T.M. Pai Endowed Chair on Public Health Genomics and Adjunct Professor at the School of Life Sciences at Manipal University, India. Before she worked in the clinics, at various academic institutions and in governmental bodies in the USA and Germany. She is Paediatrician and Specialist in Public Health Medicine, holds a PhD in pathology and a Master of Public Health from Johns Hopkins University, USA. She has been the pioneer of Public Health Genomics in Europe and beyond and established this field in more than 15 European Member States within the last years (www.phgen.eu). Public Health Genomics is the field within Public Health demonstrating the need for a holistic “systems thinking” and translating research from “cell to society” towards the implementation of personalised healthcare between key stakeholders and across sectors. The IPHG is unique in Europe giving policy advice on the national, European and global level. Key expertise and industrial collaborations include regulatory issues, use of big data for health systems and ownership questions, valorisation, decision supporting tools such as Health Technology Assessment and development of the innovative LAL model™.

Mr. Sridhar Venkapaturam
MSc Global Health and Social Justice Program, Department of Social Science, Health & Medicine, King's College London

Mr. Sridhar Venkapaturam's career and research interests have their origins in his interest in topics such as development, international political economy, and human rights. While he was planning throughout his college education on becoming an international lawyer that would work in the area of international development, an internship at Human Rights Watch changed that course. He was the first person at HRW to examine a health issue, specifically HIV/AIDS, from a human rights monitoring perspective. The difficulty of HRW to recognize a human right to health as well as the prevailing idea in public health that individual rights must be sacrificed for the greater good put him on the path of developing a philosophical argument for a moral right to be healthy. He trained in a number of relevant disciplines such a public health, sociology, economics and political philosophy. And he currently runs a graduate programme at King’s College London called Global Health and Social Justice. His research includes such topics as theories of social and global justice and health, the philosophy and ethics of health inequalities, the human right to health, the ethics and philosophy of health economics, et cetera.

Prof. Christian Lovis

Christian Lovis is professor of clinical informatics at the University of Geneva and leads the Division of Medical Information Sciences at the Geneva University Hospitals. Christian is a medical doctor trained in Internal Medicine. He is heavily involved in the Swiss federal projects around eHealth as co-chair of several working groups. He has developed the clinical information system at HUG and his involved in several large pan-European projects around using big data for bio-surveillance or clinical research. Christian is member of the governing council of HIMSS Europe and board member of HIMSS World Wide.

Mr. Andrew Filev

As the founder and CEO of Wrike, Andrew Filev is the visionary behind the unique social project management mix that has become an irreplaceable collaboration solution for thousands of customers. As a successful software entrepreneur and experienced project manager, Andrew not only oversees the company’s business strategy, but passionately leads the product management.

Prior to Wrike, Andrew Filev launched his first software development venture at the age of 17. Growing it into an international business with more than 100 engineers, he faced the same collaboration challenges that millions of companies struggle with frequently. Looking for efficient solutions, he came up with his own idea of a collaboration platform for dynamic distributed teams, running several simultaneous projects, just like his team. “Traditional software didn’t work for my team, and we weren’t alone in this. We needed a better alternative — a tool that would help connect data across multiple projects, would give a crystal-clear overview of these projects to managers and would become one hub for smooth, real-time collaboration for the whole team,” Andrew says about the origins of Wrike’s vision.

The first pillar in Andrew’s “go where data is” concept, which has become Wrike’s core, was building advanced e-mail integration to bring data from the most ubiquitous communication tools into the planning process. Further, developing Wrike as a flexible and easy-to-use system that would perfectly scale to growing teams and more data, Andrew came up with an innovative work graph model that combines the ideas from project management (work breakdown structure), operating systems (hierarchical folders), semantic web (tags) and brainstorming (mindmap) into one cohesive and simple model.

Andrew has been a contributing author in influential blogs and journals (Cutter IT Journal, Web 2.0 Journal, etc.) and has given presentations at many conferences, such as the Web 2.0 Expo, Office 2.0 Conference, PMI events and more.

Professor Suggs is an Assistant Professor of Social Marketing and Head of the BeCHANGE Research Group in the Institute for Public Communication, Faculty of Communication Sciences, at the Università della Svizzera italiana (USI), in Lugano Switzerland. She is also Director of the USI Sustainability Incubator (USI-SINC). She received a BBA in Marketing at University of North Texas (USA), a MSc and PhD in Health Studies at Texas Woman’s University (USA), and a Post-doctoral fellowship at McMaster University (Canada).

Suzanne’s research focuses on behavior change communication through information and communication technologies. She examines the determinants of behavior and tests innovative digital communication strategies, delivered through ICT, and the influence on health behaviors. The majority of her work focuses on eating and physical activity behaviors, but also does research on alcohol, tobacco, decision-making, vaccination uptake, hand washing, HIV testing, medication compliance, self-management of conditions and therapy, and consumption behaviors.

Prior to joining the faculty in Lugano, she was Assistant Professor of Health Communication, Department of Marketing Communication, at Emerson College and Adjunct Assistant Clinical Professor in the Department of Public Health and Family Medicine at Tufts University School of Medicine (Boston, Massachusetts, USA). She has a wealth of industry experience, working with pharmaceutical companies, health insurers, foundations, organizations, and multi-media communication companies. She is a Co-Founder and on the Executive Board of the European Social Marketing Association and is on the Editorial Board for the Journal of Health Communication: International Perspectives. She teaches graduate level courses in Social Marketing, Focus Group Methods, Research Methods, and Media Skills. And for the second year in a row, Suzanne will teach a course on ” m-Health: Mobile Communication for Public Health”, in the Swiss School of Public Health+ Summer School this August in Lugano.

Ms. Clotilde Rambaud-Althaus

Married, mother of two girls and MD, specialist in General Medicine (France), with a focus on Tropical Medicine and International Health. Large field experience as clinician or research scientist with Médecins Sans Frontières and Epicentre in Democratic Republic of Congo, Lebanon, Central African Republic, Cameroun, and Swaziland. Back in Switzerland after three years of expatriation in Tanzania, from 2010 to 2012 as PhD Student with Swiss Tropical and Public Health Institute and University of Basel in the field of malaria, non-malarial fever, and management of childhood illnesses. Currently finishing a PhD thesis and working as a clinician in Travel Medicine Unit of University Hospital of Lausanne.

Prof. Don de Savigny

Professor de Savigny is an epidemiologist and public health specialist and currently Head of the Health Systems Research Unit in the Department of Epidemiology and Public Health at the Swiss Tropical and Public Health Institute, University of Basel. He has extensive experience in conducting and facilitating health research in developing countries and has lived and worked for many years in Africa. He chairs or is a member of a number of WHO, RBM, Global Fund, and TDR advisory committees and networks such as COHRED, the Health Metrics Network and the INDEPTH Network. His current research focuses on interventions to strengthen health systems in developing countries, and on the health system effects of Global Health Initiatives for scaling up access.

Dr. Allison Goldberg

Allison Goldberg is a recognized public health expert who has worked with private and public sector leaders around the world on topics ranging from HIV/AIDS to maternal and child health, health innovation scale-up, and health systems strengthening. Allison has published widely and presented on these topics at national and international conferences and high-level meetings with the United States Government and United Nations. Allison spent eight years working with consumer health and pharmaceutical companies, health providers, national and local governments, and non-governmental organizations all sharing interests in developing and implementing evidence-based solutions to address global health challenges. Allison is currently the Director, Global Corporate Affairs, Anheuser-Busch InBev (ABI). In this role, Allison manages and helps develop ABI’s evidence-based research approach to advancing prudent policy related to alcohol and global health. She manages a portfolio of public health initiatives and ensures that research and best practices are embedded in these initiatives. Allison earned a B.A. in Political Science from the University of Michigan, Ann Arbor and an interdisciplinary Ph.D. in Public Health and Political Science from Columbia University.

Ms. Sabina Beatrice-Matter

Sabina Beatrice-Matter is Project Manager at the Novartis Foundation for Sustainable Development for some of the foundation’s healthcare projects, namely the primary healthcare program in Mali, the Tanzanian Training Centre for International Health as well as ICATT and IMPACtt – two eLearning initiatives aimed at improving training in maternal, newborn and child health in collaboration with WHO and the Swiss Tropical and Public Health Institute. From 2008 to 2013, Sabina was also in charge of Communication’s at the Novartis Foundation. Prior to joining the foundation, Sabina worked for the communications department at Novartis and did internships with the Swiss national television in Berne and the news agency FSN in Washington DC.

Sabina is currently doing an MBA in International Health Management at the University of Basel (graduation expected in 2015). She holds a Master’s degree in International Relations from the Graduate Institute of International and Development Studies in Geneva and the University of Salamanca in Spain and studied one year of Journalism at the Shenandoah University, USA.

2010-2012 Masters in Health Economics, Policy and Management, London School of Economics, UK

Since 2013 Health Adviser of the Swiss Red Cross

Dr. Vera Coelho

I have a PhD in social sciences in the area of “State and Public Policies” and I work at CEBRAP, an independent and interdisciplinary research center located in São Paulo, Brazil. I work with both qualitative and quantitative research methods, evaluating policies and coordinating comparative research projects in the areas of health systems, citizen involvement and pension reform. During the last twenty years I had some nice opportunities to combine professional responsibilities and personal interests as, for example, in 2008 when I went to the State of Gujarat in India to research the social justice committees at the panchayat, the local governance institutions. During my stay, I attended yoga classes, it was a great experience.

Dr. Walter Flores

Dr. Flores, a national from Guatemala, is a social scientist with over 20 years of professional experience. He holds a PhD and a Masters of Community Health from the Liverpool School of Tropical Medicine, UK. His professional work has been carried-out in more than 20 countries from Latin America, Africa, Asia and Europe. His areas of expertise are: health policy analysis, health equity, right to health, democratic governance of public policies and community participation in public policies. Currently, Dr. Flores is the director of Center for the Study of Equity and Governance in Health Systems), a civil society organization in Guatemala specialized in research, capacity building and advocacy around issues affecting indigenous and other marginalized populations (www.cegss.org.gt).

Professor Suggs is an Assistant Professor of Social Marketing and Head of the BeCHANGE Research Group in the Institute for Public Communication, Faculty of Communication Sciences, at the Università della Svizzera italiana (USI), in Lugano Switzerland. She is also Director of the USI Sustainability Incubator (USI-SINC). She received a BBA in Marketing at University of North Texas (USA), a MSc and PhD in Health Studies at Texas Woman’s University (USA), and a Post-doctoral fellowship at McMaster University (Canada).

Suzanne’s research focuses on behavior change communication through information and communication technologies. She examines the determinants of behavior and tests innovative digital communication strategies, delivered through ICT, and the influence on health behaviors. The majority of her work focuses on eating and physical activity behaviors, but also does research on alcohol, tobacco, decision-making, vaccination uptake, hand washing, HIV testing, medication compliance, self-management of conditions and therapy, and consumption behaviors.

Prior to joining the faculty in Lugano, she was Assistant Professor of Health Communication, Department of Marketing Communication, at Emerson College and Adjunct Assistant Clinical Professor in the Department of Public Health and Family Medicine at Tufts University School of Medicine (Boston, Massachusetts, USA). She has a wealth of industry experience, working with pharmaceutical companies, health insurers, foundations, organizations, and multi-media communication companies. She is a Co-Founder and on the Executive Board of the European Social Marketing Association and is on the Editorial Board for the Journal of Health Communication: International Perspectives. She teaches graduate level courses in Social Marketing, Focus Group Methods, Research Methods, and Media Skills. And for the second year in a row, Suzanne will teach a course on ” m-Health: Mobile Communication for Public Health”, in the Swiss School of Public Health+ Summer School this August in Lugano.

1Department of Community Health, Wits School of Public Health, Johannesburg, South Africa, 2School of Public Health, Wits School of Public Health, Johannesburg, South Africa, 3Centre for Health Policy, Wits School of Public Health, Johannesburg, South Africa.

Country - ies of focus

South Africa

Relevant to the conference tracks

Health Systems

Summary

With increasing global focus on the integration of vertical programmes within health systems, methods are needed to analyse whether general health service (horizontal) managers at district level exercise administrative authority over disease programmes (administrative integration). This study adapts "decision space" analysis to measure administrative integration of HIV programme monitoring and evaluation (M&E). The study shows that horizontal managers exercise high degrees of authority in producing HIV information but not in using it for decisions, while vertical managers use HIV information but in silos. The lack of M&E integration may undermine district health system strengthening aims.

Background

In South Africa, integration is a health sector reform priority, while several vertical programmes exist, notably for HIV, tuberculosis (TB), and maternal and child health (MCH). Historically a national HIV/AIDS directorate and specialist HIV managers have vertically managed the HIV programme and HIV programme managers account for ear-marked HIV programme funding through dedicated parallel reporting mechanisms. This is at odds with current health sector decentralisation reforms that envisage integrated management of health services under the control of generalist (horizontal) managers at a decentralised district level. National health policy envisions health districts as the foundation of the national health system.

Objectives

If health districts are to be the foundation of the health system as envisaged, then horizontal district managers would need to be allocated and to exercise authority over district health services, including disease-specific interventions (i.e. administrative integration). This study examines whether this is happening in the South African health system. We use the HIV programme as a case study given its traditionally vertical approach, and focus on the M&E (information) function as a tracer for analysing administrative integration. The research aims are to:
1. Describe the extent to which horizontal managers exercise authority over HIV M&E coordination.
2. Explore factors associated with exercised authority.

Methodology

The research explores two hypotheses: a) vertical managers exercise higher degrees of authority than horizontal managers in administering HIV M&E; and higher management capacity and HIV M&E knowledge are associated with higher degrees of exercised authority. This cross-sectional study was conducted in two of South Africa’s nine provinces. Fifty one participants were interviewed including: a) managers primarily responsible for general health services or general health information (horizontal manager) and b) those responsible for vertical services or information (vertical manager). HIV M&E was defined as the production of HIV information (HIV data collection, collation, analysis) and use of HIV information for decisions.In the absence of existing methods for measuring 'exercised authority' over vertical programmes, Bossert's decision-space’ approach provided a useful frame. Since decision-space analysis has not been applied to either the M&E function or in the context of programme integration, it was adapted to measure ‘exercised (administrative) authority’ in this study. We defined exercised authority as a manager undertakes tasks to oversee HIV data collection, collation and analysis, and uses HIV data to review the programme and take action. To measure this, we first identified the M&E tasks that managers were expected to perform within each M&E domain (collection, collation, analysis, use) and then administered a semi-structured questionnaire to collect data on participants’ performance of these tasks. We developed four sub-scales to measure the degree of exercised authority for each M&E domain. Sub-scales comprised several items (M&E tasks), which we coded ‘no’ if a respondent did not perform the task (score zero) or ‘yes’ if s/he did. We computed an ordinal dependent variable for each HIV M&E domain and coded observed scores as ‘low’, ‘medium’, and ‘high’. We performed ordinal logistic regression to explore whether explanatory variables (actor type [horizontal or vertical], health system level, highest, qualification, duration of management experience, management capacity score, and M&E knowledge score) were predictive of higher degrees of exercised authority.

Results

More than 75% of participants were female, with an undergraduate degree or higher, and had some management
training. Participant characteristics were similar between vertical and horizontal managers. Horizontal managers attained higher mean scores for HIV data collection.

Conclusion

In light of the increasing focus on health system strengthening and integration, our research makes a contribution
by providing a method and scales for measuring and monitoring administrative integration. We anticipate that
these scales will be strengthened further by empirical testing on larger samples and varied settings. In applying this
method to South Africa’s public sector HIV programme, we find that HIV M&E coordination is generally not administratively integrated, characterised by horizontal managers exercising little authority in using HIV data, and vertical managers using HIV data in sub-programme silos. We argue that this programme model potentially undermines South Africa's policy aims of integrated management of district health services under the authority of horizontal general health service managers. The research also indicates that plans for integrating the HIV programme within the health system at decentralised district level should include investments in strategies to equip horizontal managers with the knowledge and skills to use programme data for decision-making.

The Rwanda Health Information Exchange (RHIE) is among the world’s first efforts to establish an integrated national health information system in a low-resource setting. Global decision-makers and implementers can benefit from both RHIE's open source tools and knowledge of leading and managing innovation for integration. This study assesses best practices in the design, development, and deployment of RHIE from the perspective of key stakeholders. Themes from the analysis of semi-structured interviews with funders, leaders, and implementers include recommendations on governance of country-owned initiatives, technological design and development, and deployment in a low-resource setting.

Background

RHIE is a cloud-based system that supports quality of care and continuity of care over time, across geographies, and across different care delivery sites. RHIE’s vision is to improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different information systems used nationwide. In 2010, RHIE was designed and developed under the leadership of Rwanda’s Ministry of Health by the Open Health Information Exchange (OpenHIE), a global open-source technology community including partners at PEPFAR, Canadian International Research Development Center, Rockefeller Foundation, Regenstrief Institute, InSTEDD, Jembi Health Systems, IntraHealth, and others. RHIE’s national rollout began in 2012 and entailed working across sites with minimal infrastructure and among providers with little computer experience to configure hardware, install software, build local capacity, and manage technical support . Today, and as scale-up continues, RHIE facilitates the movement of health information across Rwanda with the primary aim of improving maternal and child health and the treatment and prevention of HIV/AIDS.

Objectives

The Open Health Information Exchange builds free and open-source tools to enable other national leaders, policymakers, and implementers to improve the integration of health data and systems through the establishment of health information exchanges. Today, the partnership is collaborating with national leaders from six countries, providing technical support required to spearhead this effort. However, more than just tools and technical support, decision-makers need practical insights into the process of leading and managing innovation of this kind. As such, this study aims to describe the best practices in design, development, and deployment of a health information exchange, based on the RHIE experience. Researchers conducted key stakeholder interviews among RHIE funders, leaders, and implementers with a range of expertise from computer engineering to health systems management to clinical care. From their critical reflections of the RHIE initiative, its three years of history, and its pathways forward, stakeholders provide recommendations on approaches to governance of country-owned initiatives, strategies for technological design and development, and tactics for managing deployment of technological innovation in low-resource settings.

Methodology

Qualitative semi-structured interviews were conducted with RHIE key stakeholders. Stakeholders included Ministry of Health leaders & implementers, project managers & strategists, technology architecture designers & developers, and funders & other institutional partners. Semi-structured interviews guided a conversational interview, providing the interviewers with key points of discussion without requiring strict adherence to a set order of questioning or phrasing of the questions. As such, interviewees provide descriptions of their experiences, ideas, and critiques in an open and guided discussion. Interview were conducted by two trained interviewers via phone, audio-recorded, and documented through detailed notes. Interview duration ranged from 45-75 minutes. Analysis was conducted using Dedoose Mixed Methods Analysis Software, a cloud-based research and analysis application. A modified grounded theory approach was used in the analysis of qualitative data. This approach facilitated the detailed and systematic examination of data regularities in the relationships between and within codes, and for variations and contrasts within codes. Major themes emerged from the codes and a descriptive framework formed.

Results

Key stakeholder interviews included 14 participants from 7 organizations and 4 countries. Several key themes emerged across the major phases, spanning partnership building, design, development, deployment, and evaluation. First, eHealth is a new field without established guidelines for management and leadership and, as such, most found it challenging to partner without clearly articulated governance rules. Terms of governance, they argued, provide guidance for decision-making, roles and responsibilities, accountability, and transparency. The RHIE experience confirmed for most that country-ownership of the initiative should be established early and embedded into the partnership’s governance structures.Second, most partners commented on the difficulty of collaboration when key contributors were spread across several countries and time-zones. They explained that in a low-resource setting, it is often necessary to look for eHealth integration expertise and capacity from people based in other countries. Cross-cultural, cross-national, and cross-disciplinary communication was immensely difficult, although building an integrated system required a well-integrated team. Stakeholders found that it was critical to have a shared commitment to regular communication and ample budget for in-person meetings.Third, experts were adamant that an eHealth integration initiative should start by looking at existing, tested, and ideally open-source tools that might serve as customizable building blocks for their own solution. While identifying these tools, most argued that the team must create a shared standard of assessment so that they can transparently evaluate tools in a world where business interests may sway these decisions. Many stakeholders shared the opinion that eHealth solutions must be simple, tested, and even boring, although “the siren song is to do something new, bold, and innovative.”Finally, most partners found that the health and human development objectives of the project were obfuscated by the technological objectives of the project. RHIE contributors spent the vast majority of their efforts on designing and developing the technology, often without a shared vision of how the system would ultimately impact health services, morbidity, and mortality. One expert argued that it should have been the opposite and that “in a sociotechnical system, the technical should be 10% and the rest of the money and time should be spent focusing on implementing.”

Conclusion

The health systems integration experts involved in RHIE shared a common sense of the challenges and opportunities inherent in partnering, designing, developing, and deploying a health information exchange. Several best practices emerge from these findings: establish rules of governance to guide the partnership; plan for regular and in-person communications to facilitate collaboration among diverse contributors; build on existing, tested, and open-source technologies before considering anything new; and, create a shared strategic and practical vision for how a new eHealth tool will impact health. As the OpenHIE expands beyond Rwanda and into new country implementations, these findings can be used to guide policy-makers, implementers, and other experts. Worldwide, country leaders are struggling to take advantage of the digitization of health information while managing innovation within health centers and protecting patient privacy. In an era of big data, health information exchange is one way to integrate and manage health information across disparate systems. Health information exchange tools and best practices may improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different health information devices, tools, and systems emerging worldwide.

For health interventions to be successful, not only the health system needs to be considered, but also the patients understood. However, often in health research this understanding is reduced to their socio-economic status.
The present empirical study, focusing on the reasons for (non-) enrolment in voluntary health insurance schemes in rural Mali, expands the analysis of household characteristics to sociocultural orientations and intra-familial structures, including decision-making patterns.
The results reveal that the socio-economic status of households does not explain membership in a health insurance scheme, whereas the attitudes heads and family decision making patterns clearly do.

Background

Systematic, quantitative evidence on user characteristics of health interventions is mostly limited to socio-demographic features and economic status. Yet, as research in medical anthropology has revealed, the acceptance of health related innovations is not only dependent on these factors.The example of (non-)enrolment in voluntary health community-based insurance schemes in sub-Saharan Africa mirrors this research gap. These schemes are characterized by modest enrolments rates and do not tap their potential in an already limited catchment area. In order to increase their coverage, the reasons for (non-)enrolment need to be better understood.However, to date, research has focused on the supply side, i.e. features of the insurance schemes and their contracted providers. On the demand side, comparative studies of enrolled and non-enrolled households have mainly concentrated on their socioeconomic status.Three research gaps remain which are not unique to the analysis of community-based health insurance: 1) sociocultural features are not analyzed in a quantifiable manner as socio-economic characteristics are. 2) household and family structures and their decision making patterns are not considered. Thirdly, significant factors are not explained and related to each other.

Objectives

The present empirical study aims to fill the following research gaps:1) to expand the analysis of household characteristics beyond households’ socio-economic status by also taking account of their sociocultural orientations and intra-familial structures, including decision-making patterns. The main hypothesis underlying this approach is that socio-economic differences have been overestimated regarding their importance in determining the uptake of innovations, i.e. in the presented case membership in health insurance schemes, whereas attitudes and values, such as openness to or mistrust of social innovations, have been underestimated.2) A further goal is to systematically bring together and interrelate influencing factors that are meaningful beyond statistical significance, in order to ultimately reveal different lifestyle patterns associated with membership in, or refusal to join, a health insurance scheme.3) A further aim of this study is to present an analytical framework that links the socio-economic characteristics of households with their sociocultural orientations as well as with household and family structures.

Methodology

A mixed methods approach, with different instruments employed sequentially, was developed. The central rationale behind a mixed-methods approach of this type was the idea to use qualitative methods of data collection not only in the exploratory phase but also at a later stage, to enhance interpretation of results from quantitative statistical data analysis and to develop explanatory patterns.The core element of the mixed methods approach chosen was household surveys on lifestyle patterns and social protection strategies. A total of 600 heads of households were interviewed in two localities. Of these, in each locality 200 had no insurance, while 100 did have insurance. In a second survey round, half of these household heads were again interviewed about their social protection strategies. In each study area this round covered 100 households with insurance and 50 households with no insurance.Households were the focus of research for two reasons: on the one hand, they are the unit of membership in the community-based health insurance schemes being studied. On the other hand, households are important repositories of lifestyle patterns within society and have a great degree of influence on the activities of their members. This is manifested, for example, in the transmission of values between generations and in the sharing of resources. Moreover, households are units of decision-making in different areas of life.Comparison of two rural areas in Mali had been considered useful insofar as community-based health insurance schemes are being advocated for peasant populations, primarily in French-speaking Africa. Furthermore, the two localities differ in terms of climate and in socio-economic and sociocultural terms but have a very similar health insurance scheme. Comparison of two areas also made it possible to examine to what extent social differences exist in rural Mali.

The household surveys were preceded by an exploratory phase including group and individual discussions, which primarily served to identify locally relevant categories of social differentiation. Following the household surveys, preliminary results were presented to representatives from the municipalities. These discussions brought out new points of view that were of use in further data collection and analysis. Following this, 20 group discussions and 24 individuals from selected families were interviewed in order to obtain insights into household and family decision-making patterns.

Results

The results reveal that the socio-economic status of households does not explain membership in a community-based health insurance scheme, whereas the attitudes of household heads and family decision-making patterns clearly do. For instance, households of the lower socioeconomic tercile were even slightly more likely to be members than those of the middle tercile (p-value: 0.669; CI: .63-2.02; OR: 1.13).Households that are single households or are not part of a large family have greater freedom in decision-making. Moreover, heads of households with insurance appreciate different social changes (e.g. existence of new, formal organizations including community-based health insurance schemes), take on responsible roles in their communities and plan in a manner where the benefit is unsure or not immediately given, significantly more often than heads of uninsured households. For instance, those heads of household who only utter negative social changes are significantly less likely to be insured than those who also mention positive changes (p-value: 0.000; CI: .21-.57; OR: .35).Based on the results, a typology of households and their lifestyle patterns was empirically determined in both study areas. Each of the two study areas, two different household types were identified that are distinct not by their socio-economic status but by family structure and sociocultural orientation. The existence of different household types in both areas underscores the clear social differences that exist in rural Mali.

Conclusion

The findings from this research on the reasons for (non-)enrolment of households in community-based health insurance schemes in rural Mali reveal that limiting the "users" of health interventions to their socio-economic status in many circumstances does not sufficiently explain why people "lack access to" or do not take up the services offered through health interventions.In order to better target potential users of health interventions and increase coverage, a more comprehensive but systematic analysis of their characteristics must be done. This includes socio-cultural features such as attitudes towards social innovations and change, leading values, consumption priorities as well as decision making patterns at household and family level.In other words, for health interventions to be successful, not only the heath system and its actors need to be considered, but also the patients. However, they must not be reduced to people living in poverty. Rather research must acknowledge that they are characterised by different livelihood patterns that expand beyond the issue of poverty.

1Department of Sociomedical Sciences, Columbia University, Mailman School of Public Health , New York , United States, 2Department of Epidemiology, Columbia University, Mailman School of Public Health , New York, United States, 3Department of Epidemiology, Columbia University, Mailman School of Public Health , New York, United States.

Country - ies of focus

United States

Relevant to the conference tracks

Governance and Policies

Summary

The overall aim of this project is to systematically detail the timing and substance of health-relevant New York City (NYC) policies and initiatives from 2002-2013. This is the initial phase of research proposing to evaluate the effectiveness of these efforts in reducing chronic disease morbidity and mortality rates. Local governments around the United States have taken policy action to mitigate the adverse effects of health determinants beyond the health care sector, such as tobacco smoke, physical inactivity, low dietary quality, and air pollution. NYC has been at the vanguard of municipal efforts to decrease the chronic disease using a multi-sectorial approach.

Background

Chronic diseases represent the leading causes of death and disability among developing and developed nations (Yach et al, 2004; Beaglehole & Bonita, 2008). Among the most deadly chronic diseases, are atherosclerotic cardiovascular disease (CVD) and cancer, accounting for >65% of global mortality in 2002. This is projected to remain stable through the year 2020 at which point CVD and cancer together will account for nearly 40 million global deaths – nearly twice the number of deaths projected due to injuries and infectious disease combined (Yach et al, 2004). Respiratory diseases including emphysema and chronic obstructive pulmonary disease (COPD) are projected to become the third most common cause of death by 2020, accounting for another 10% of global mortality. It is well established that leading modifiable risk factors for chronic disease development include tobacco use, excess adiposity, low dietary quality, and exposure to particulate air pollution. The increasing concentration of populations in urban centres, while previously discussed as potentially contributing to risk (Vlahov, 2002), also represents an opportunity to enhance the public’s health through the enactment of local health promotion efforts in densely populated cities such as New York City.

Objectives

Over the past twelve years, NYC has been led by the Michael Bloomberg administration, which has prioritized public health initiatives in response to the chronic disease burden of New Yorkers. Bloomberg worked closely with Health Commissioners, but the efforts were not limited to Department of Health and Mental Hygiene. A variety of governmental approaches including taxation, regulation, marketing/advertising campaigns, and infrastructure investments were proposed and implemented throughout the five boroughs. If the Bloomberg administration significantly decreased the chronic disease burden of the city dwellers, such policies can guide the nation to similar results. Currently, a comprehensive catalogue of all health-related NYC policy proposals, enacted laws and implemented initiatives does not exist.The aim of this research project was to systematically catalogue the nature and deployment of policies and initiatives relevant to public health. We will specifically focus on policies and programs enacted in NYC during the Bloomberg Administration, 2002-2013, related to the following four chronic disease risk factors: 1) tobacco, 2) obesity, 3) diet quality, and 4) air quality.

Methodology

This study identifies policies and initiatives relevant to public health proposed and enacted in NYC. Specifically, it addresses the following research questions: (1) How many policies and initiatives related to public health were proposed and enacted in NYC legislation during 2002-2013 (2) Which local governmental agencies and departments were involved in the enact of such efforts.The systematic development of the catalogue of relevant policies and initiatives was generated in three phases. First, online state and city legislative record portals (assembly.state.ny.us, nyc.gov, legistar.council.nyc.gov/Legislation.aspx) and the PubMed database have been used with search terms for each of the selected chronic disease risk factors. Secondly, the searches were narrowed by selecting specific terms for each of the four chronic disease risk factors. For example, when searching legislation in regards to air pollution, the following terms, (air quality, air pollution, and greenhouse gases) were systematically used to provide consistency and a thorough assessment of relevant policies. Lastly, the search was restricted to include only the years of 2002-2013, the Bloomberg Administration’s term in office. The final catalogue includes the policy legislation number, date created, date enacted (if applicable), data enforced (if applicable), current status (as of August 2013), the primary agency that sponsored the bill, and a brief description. Note only citywide policies and regulations were included in the final catalogue.

Results

Overall during 2002-2013 there were a total of 113 policies relevant to public health that were introduced and 33 enacted. Legislation that reduced the risk factor of tobacco included 33 introduced and 7 enacted policies. The New York City Council’s committee of health sponsored the majority of this legislation. The most notable legislated passed includes: Smoke Free Act of 2002, Cigarette Tax Increase, Smoking Ban at Abatement Sites, Smoking Ban at Construction Sites, Smoking Ban at Hospitals, Tobacco Product Regulation, and Smoke Free Act of 2002 (Amendment). Legislation that reduced the risk factor of air quality included 32 introduced and 12 enacted policies. The New York City Council’s committee of environmental protection sponsored the majority of this legislation. The most notable legislation passed includes: Use of clean heating oil in New York City, Requiring retrofitting and the use of ultra-low sulphur diesel fuel for school buses that transport fewer than 10 students at one time, and City's purchase of cleaner vehicles. Legislation that reduced the risk factor of physical activity included 13 introduced and 2 enacted policies. The New York City Department of Health and Mental Hygiene sponsored the majority of this legislation. The most notable initiatives include the increase of bike lanes throughout the city as well as the Citi Bike public bike sharing system. Legislation that reduced the risk factor of diet quality included 35 introduced and 12 enacted policies. The New York City Council’s committee of health sponsored the majority of this legislation. The most notable legislated proposed was the Sugary Drink Size Ban and Minimally nutritious food ban in schools. The most notable legislation passed includes Maximizing the enrolment of eligible New Yorkers in the food stamp program and the Trans fats ban.The process of developing the catalogue of public health related polices and initiatives is limited by the information that was available on the online city and state portal as of August 2013. In addition, some citywide initiatives were programs that did not require legislation thus those projects and programs are not included in the presented catalogue. Moreover, at this time the health outcome data has not been analysed thus it is not possible to quantify the impact of such polices on the health of New Yorkers which is our overall goal.

Conclusion

This initial effort has highlighted that changing temporal trends in chronic disease outcomes may be attributed to one or many of the concurrent efforts, and evaluations of any one approach should be at once cautious and clever. The catalogue presented is the preliminary phase of an on-going research project to identify the magnitude and effect municipal policies impact health outcomes. Our future research includes strategies to place the temporal patterns of legislation relevant to each risk factor (Figure 2) in the broader context of other local or citywide efforts. Through this work, it will be possible to describe the cumulative “dose-response” relationship of municipal policy initiatives with population health outcomes. Strategies are also proposed using outcome specificity, differential latency periods, and multiple control comparisons that may help us to distil some evidence on the relative effectiveness of particular policies or risk factor targets. Further, we hope through an examination of scientific citation networks to shed light on the evidence base supporting such efforts. This consensus building analysis aims to provide a clearer picture of the stages at which scientific knowledge may inform decision-making, and the opportunities for municipal policies to serve as natural experiments to foster the generation of new scientific knowledge. Upon the completion of this research information about how local policies are developed, implemented can be applied to the future development of disease prevention polices.

There is increasing global attention on Non-Communicable Diseases (NCDs). In the Philippines, the burden of NCDs is growing but government response remains weak. The study is a policy research that looks at the development of a new benefit package for non-communicable diseases within the Philippine social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed in shaping the policy. The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.

Background

There has been increasing attention to non-communicable disease (NCDs) globally since the run-up to the high-level summit at the United Nations in September 2011 (Beaglehole 2011). In the Philippines, the burden of NCDs is growing (Shaw 2010). Although the government has started to develop policies and programs to address NCDs, there is still poor financing especially for prevention activities and comprehensive primary care services, lack of health human resource and weak political support (Higuchi 2010; Dans 2011). At the community level, the implementation of NCD programs, comprising mainly of healthy lifestyle clubs and occasional screening activities, remain weak (Lorenzo 2011). Overall, there is an inadequate response considering increasing burden of disease (Bermejo 2011; Van Olmen 2011).The improvement of the health financing mechanisms and particularly of the national health insurance agency, PhilHealth, is seen as a key in decreasing inequities and improving access (Romualdez 2011). One of the new Philhealth benefit packages that is ready to be piloted is the “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia” also known as the "Primary Care Benefit 2" (PCB2).

Objectives

The study is essentially a policy research which looks at the development of a new benefit package for non-communicable diseases within the Philippines social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed to shaping the policy. The study will also identify different streams in the discourse around PCB2 and analyze how and why this specific policy window emerged.Philhealth is emerging to be one of largest purchasers of healthcare services in the Philippines. It is an agency attached to the Department of Health and is increasingly seen as one of the institutions that shape the healthcare landscape in the country. This research will help to gain insight into its policy making processes, what and who these affect and how these are influenced. This study will help us identify opportunities for improvement of the policy processes at Philhealth and develop recommendations to inform current health policy.

Methodology

Study design
A case study methodology was done using both qualitative and quantitative methodologies. Documents and issuances related to the development of PCB2 including Administrative Orders, Philhealth Circulars, other legal issuances, and reports of key meetings and events were reviewed. Key informant interviews were conducted among an initial list of actors involved in the development of this new benefit package to gain insight into the key decision made, why these decisions were made and how such decisions were arrived at. The snowballing technique was employed to identify other potential interviewees. The study aimed for theoretical saturation. A trend analysis on quantitative data from the Philhealth database on inpatient claims for NCDs was performed to enrich the contextual description of the case.Sampling
A total of 28 key informant Interviews were conducted with actors involved in the development of PCB2, including:
1. Philhealth decision-makers (e.g. the former and current president of Philhealth, technical personnel within the Primary Care Benefit Team);
2. Program managers and decision-makers at the Department of Health specifically those who are concerned with primary care, NCDs, access to medicines and local health systems development;
3. Members of the academe and researchers consulted on PCB2;
4. Representatives of advocacy groups on Universal Health Care and NCDs;
5. Health officers and representatives of local governments selected as pilot sites;
6. Representatives of the private pharmaceutical sector in the Philippines.Analysis
The policy triangle (Walt and Gilson 1994) and Kingdon’s policy window theory (Kingdon 1995; Guldbrandsson 2009) was applied to analyze the case. The researchers reconstructed the story of the development of PCB2 and identified key strategic decision-making points in the development process. We analyzed how the policy was shaped by the interaction between the context, actors and process. We enriched the contextual description with the time trend analyses of Philhealth population coverage, NCD-related inpatient claims, and reserve funds. The study also identified different streams in the discourse around PCB2, including the discussions on Universal Health Care, NCDs, primary care, strengthening local health systems, and analysed how and why this specific policy window emerged. The research approach was iterative. Each set of data analyzed were used to construct and test the theory.

Results

We identified four key elements in the new outpatient benefit package of Philhealth: 1) only for sponsored program members or the bottom poor enrolled into the program by the national and local governments, 2) use of the WHO Package of Essential Noncommunicable (PEN) Disease Intervention guidelines for screening and risk scoring, 3) access to full monthly regiments of 8 firstline NCD medications which were 4) made available through contracted private pharmacies.The focus on the bottom poor is consistent with the overall poverty reduction strategy of the government. The strategy is to concentrate poverty alleviation interventions (e.g. Conditional Cash Transfers, enrolment in social health insurance) among the bottom poor (20% of the population) identified through a national household targeting system for poverty reduction.The use of the PEN guideline for screening and risk scoring was a result of consultation with the World Health Organization (WHO) and with the health managers of the City of Pateros where the guidelines were being piloted. Setting risk scores was seen by the insurance managers as a good way to have control over the cost exposure of Philhealth on this new benefit package. This was further validated by expert consultants in Medicine.The first line generic medications included in the list covered by the benefit package was arrived at with the technical team validating the evidence around NCD drugs included in the Philippine National Drug Formulary. By law, all government agencies, including Philhealth, can only pay or procure medicines that are included in the formulary. The position of Philhalth is to promote rational drug use and is directed at the common practice of many physicians who prefer originator drugs. Representatives of pharmaceutical companies, public health centers and specialist doctors actively raised the issue of the "very limited" list of medicines covered by the package.

The decision to make the NCD medicines available through contracted pharmacies is to be consistent with the Pharmacy Law but also largely depoliticizes access to drugs and link it as a clear benefit of being a Philhealth member. Access to medcines made available through public primary care facilities are often politicized.

The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.

Conclusion

Health policies, programs and and agendas do not exist in separate silos from each other. PhilHealth’s “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia" or "Primary Care Benefit Package 2" (PCB2) is one such policy whose development was shaped by policy development processes, actors pushing for their specific agenda and by the context. The actual policy is a product of the dynamic interplay of these factors.

This presentation aims to show how participatory techniques can be effectively embedded within government health and community development structures to successfully support community action for health and well-being and at the same time contribute to broader positive social change and equitable access to health services.
By using participatory techniques and at the same time mainstreaming gender, HIV and social equity, within the project itself, as well as at the community and government levels, the Health Promotion and System Strengthening Project (HPSS) takes a broad human rights, equity and inclusive approach, to improve the health and well-being of all members of the community.

What challenges does your project address and why is it of importance?

The HPSS Project aims to improve the health status and well-being of all members of a community through innovative approaches, with a particular emphasis on the support of vulnerable people, such as women, children, elderly and socially disadvantaged. A special focus is to ensure that all aspects of project implementation and information will maximize the potential to include all sectors of society in community health promotion and address existing inequalities. However, most often communities - and in particular vulnerable groups - do not have an arena in which to raise their voice and address their health concerns, while the possibility of involvement is low.
The project therefore aims to empower communities and their members to identify and express their health needs and demand equitable access to appropriate health care and social services. By addressing local needs and supporting community action for health, the projects aims to establish sustainable community mechanisms and strongly link them with government and non-government structures for sustainable results that contribute to improve health and well-being of all people in the region.

How have you addressed these challenges? Do you see a solution?

This presentation will demonstrate how the project translates the Ottawa Charter onto the ground in the context of Dodoma Region and report on early operational research outcomes of the Regional pilot for health reform.
In adapting the health and community development systems to strengthen health promotion, the project has negotiated adapted terms of reference and trained-as-trainers Community Health and Development Officers (CHOs and CDOs) as well as School Health Coordinators (SHC) in community participatory techniques and cutting edge health promotion approaches. As master trainers, with support of HPSS District Coordinators, these government cadres have rolled out a tailored training packages to their assistants, Non-Governmental Organizations (NGOs), Faith Based Organisations (FBO), Community Based Organizations (CBOs) and communities themselves. Following consultative workshops, regional governments agreed to expanded health promotion roles of the Region’s 152 CDOs and their assistants. They work together with Health Officers to support communities, through participatory methods, to identify local health concerns, as well as resources and to plan solutions. In this process the trained government CHOs and CDOs and SHCs facilitate communities to identify their health concerns and solutions in a participatory meeting of peer groups - disaggregated by sex and age as well as by concern groups – such as the disabled. After initial community-led discussions, facilitators showed discussion groups how to quantify their priorities and the group subsequently voted for their primary health concerns. The results of the sub-groups were then presented by the facilitators to the whole community in a final meeting, emphasising the very different priorities of men and women, and different age groups in the same community. This usually resulted in a direct community discussion and debate concerning different perceptions on health and well-being issues within the community. Following this, the community as a whole, facilitated by their trained CDO, prepared a community health promotion plan for presentation to local councils for inclusion within and funding with the Council Comprehensive Health Plans.

How do you know whether you have made a difference?

In the process Regional authorities have raised the importance and profile of inclusive, participatory approaches by adding these duties to government staff terms of reference. The strengthening of health promotion, gender and social inclusion approaches within community led-processes has not only improved grass-roots level dialogue and action on local health and social concerns but strengthened the capacity and networking of community-based organisations. This has also set in motion means by which communities can not only take action to address issues in the local context, but access existing funding lines for community health activities. The Participatory Rural Appraisal (PRA) process has been rolled-out to all communities in the 7 districts of Dodoma region. Even at this early stage of the project, PRA outcomes resulted in community health action plans, which have been inclusively developed in more than 200 villages. A total of 220 health promotion action plans have been developed by communities in this way, reflecting 16 priority health-related themes.
By taking an inclusive approach that sensitises government and non-government facilitators, the solidarity and empowerment of traditionally marginalised and stigmatised groups including women, the poor, people living with HIV and affected by AIDS and people living with disabilities has also been strengthened.

Have you or the project mobilized others and if so, who, why and how?

Approaches chosen within the HPSS Project have mobilized people on several different levels. Primarily, government CHOs, CDOs and SHCs were trained-as-trainers in facilitating community participatory techniques and cutting edge health promotion approaches. This has led to their expanded health promotion roles in accordance with the regional governments. The master-trainers have rolled out these techniques to all government staff and community organisations in the region. Applying a bottom-up approach, government officers facilitate communities to identify their health concerns and solutions in a participatory manner.

When your donor funding runs out how will your idea continue to live?

The HPSS Project, implemented by the Swiss Centre for International Health (SCIH)/Swiss Tropical and Public Health Institute (Swiss TPH) on behalf of the Swiss Development Cooperation Agency (SDC), is subdivided into three project phases, namely a pilot implementation phase from the year of 2011-2014, a consolidation and scaling-up phase between 2015 and 2017 and the completion of a nationwide scale-up in the years of 2018-2020.
By training a cadre of master trainers within government and non-government structures in the first phase of the project in Dodoma region, novel inclusive approaches have been rapidly cascaded to the communities for complete geographical coverage. The inclusive, participatory techniques used effectively advocate for the different health priorities of various groups within community’s debates, inclusive action planning and ensure that these actions are funded and realised.
As approaches have been embedded in the skills and responsibilities of government staff, this allows the direct involvement of community members, in particular giving voice to vulnerable groups. These inclusive, participatory techniques are likely to be sustained and replicated as a nationwide scaling-up of the HPSS approaches and activities in subsequent phases. Furthermore, the project has developed and launched a short course (in June 2012) on participatory techniques for inclusive community action for health promotion at the Zonal Training Centre. This will contribute to sustainability by providing focussed training of development and health staff in the coming years and act as regional resource centre for these activities.